Independence, institutionalization, death and treatment costs 18 months after rehabilitation of older people in two different primary health care settings

Better functional recovery after acute stroke in older patients managed in a new dedicated post-stroke geriatric unit compared to usual management

OBJECTIVES

A Stroke care Pathway dedicated to the ELders (SPEL) for patients with acute stroke was created in 2013 at the hospitals Pitié-Salpêtrière-Charles Foix (Paris, France). It is characterized by a stroke unit dedicated to emergency stroke care, and a post stroke geriatric unit (PSGU) including rehabilitation and management of geriatric syndromes. The aim of the study was to compare the functional recovery of patients transferred to PSGU versus other rehabilitation care in patients over 70 years of age after stroke.

DESIGN

A cohort observational study over a 4-year period.

SETTING

Hospitals Pitié-Salpêtrière and Charles Foix (Paris, France).

PARTICIPANTS

We studied patients over 70 years admitted to the participating stroke unit for acute stroke consecutively hospitalized from January 1, 2013, to January 1, 2017.

INTERVENTION

Patients transferred in the PSGU were compared to those admitted in other rehabilitation units.

MEASUREMENTS

The primary outcome was 3-month functional recovery after stroke. The secondary outcomes were the hospital length of stay and the returning home rate. A multivariable logistic regression was applied to adjust for confounding variables (age, sex, NIHSS score and Charlson's comorbidity score).

RESULTS

Among the 262 patients included in the study, those in the PGSU were significantly older, had a higher Charlson's comorbidity score and a higher initial NIHSS severity score. As compared to the other patients, functional recovery at 3 months was better in the PSGU (Rankin's score decreased by 0.80 points versus 0.41 points, p = 0.01). The average total length of stay was reduced by 16 days in the patients referred to the PSGU (p = 0.002). There was no significant difference in the returning home rate between the two groups (p = 0.88).

CONCLUSION

The SPEL which includes a post-stroke geriatric unit (PSGU) has been associated with improved recovery and had a positive impact in the management of older post-stroke patients.

Balancing standardisation and individualisation in transitional care pathways: a meta-ethnography of the perspectives of older patients, informal caregivers and healthcare professionals

BACKGROUND

Transitional care implies the transfer of patients within or across care settings in a seamless and safe way. For frail, older patients with complex health issues, high-quality transitions are especially important as these patients typically move more frequently within healthcare settings, requiring treatment from different providers. As transitions of care for frail people are considered risky, securing the quality and safety of these transitions is of great international interest. Nevertheless, despite efforts to improve quality in transitional care, research indicates that there is a lack of clear guidance to deal with practical challenges that may arise. The aim of this article is to synthesise older patients, informal caregivers and healthcare professionals' experiences of challenges to achieving high-quality transitional care.

METHODS

We used the seven-step method for meta-ethnography originally developed by Noblit and Hare. In four different but connected qualitative projects, the authors investigated the challenges to transitional care for older people in the Norwegian healthcare system from the perspectives of older patients, informal caregivers and healthcare professionals. In this paper, we highlight and discuss the cruciality of these challenging issues by synthesising the results from twelve articles.

RESULTS

The analysis resulted in four themes: i) balancing person-centred versus efficient care, ii) balancing everyday patient life versus the treatment of illness, iii) balancing user choice versus "What Matters to You", and iv) balancing relational versus practical care. These expressed challenges represent tensions at the system, organisation and individual levels based on partial competing assumptions on person-centred-care-inspired individualisation endeavours and standardisation requirements in transitional care.

CONCLUSIONS

There is an urgent need for a clearer understanding of the tension between standardisation and individualisation in transitional care pathways for older patients to ensure better healthcare quality for patients and more realistic working environments for healthcare professionals. Incorporating a certain professional flexibility within the wider boundary of standardisation may give healthcare professionals room for negotiation to meet patients' individual needs, while at the same time ensuring patient flow, equity and evidence-based practice.

Combining scoping review and concept analysis methodologies to clarify the meaning of rehabilitation potential after acquired brain injury

PURPOSE

Clinicians make judgments about patients' rehabilitation potential because it is considered by many as a prerequisite for referral to rehabilitation. However, the concept is rarely defined. This research aimed to clarify the concept of rehabilitation potential in the context of acquired brain injury patient referral to post-acute rehabilitation.

METHOD

Literature search (conducted in Medline, CINAHL and Embase) and article selection followed a scoping review methodology while a concept analysis methodology guided data extraction and analysis.

RESULTS

Eighteen documents met inclusion criteria. Findings suggest four defining attributes of the concept. Rehabilitation potential (1) emerges from clinicians' interpretation of patient characteristics and is influenced by the health care environment, (2) involves the prediction of how a patient might improve with rehabilitation interventions, (3) is a multi-level concept and (4) can change over time. The most critical consequence to assessing a patient's rehabilitation potential is the impact on the patient's opportunity to access post-acute rehabilitation services.

CONCLUSION

Rehabilitation potential is a concept rooted in clinical reasoning. We propose an operational definition and a conceptual model to provide a solid foundation for future research to advance policy and clinical decision-making regarding equitable access to post-acute rehabilitation.IMPLICATIONS FOR REHABILITATIONRehabilitation potential is a concept rooted in clinical reasoning and emerges from clinicians' prediction of how a patient might improve with rehabilitation interventions.Rehabilitation potential is not a dichotomous concept but a multi-level concept with each level falling along a continuum.It may be inaccurate/inappropriate to definitively state that a patient has or does not have rehabilitation potential, as patients may demonstrate varying levels of rehabilitation potential.Rehabilitation potential can change with time requiring re-assessment to readjust recommendations accordingly with regards to appropriate rehabilitation interventions at any given time.

Rehabilitation potential in older people living with frailty: a systematic mapping review

Background

Following periods of acute ill-health and injury, older people are frequently assessed and provided with rehabilitation services. Healthcare practitioners are required to make nuanced decisions about which patients are likely to benefit from and respond to rehabilitation. The clinical currency in which these decisions are transacted is through the term “rehabilitation potential”. The aim of this study was to explore information about rehabilitation potential in older people to inform the development of an evidence-based assessment tool.

Methods

A systematic mapping review was completed to describe the extent of research and the concepts underpinning rehabilitation potential. We searched Medline, CINHAL, EMBASE, AMED, PsycINFO, PEDro, Cochrane Library, Web of Science, ProQuest, Trip and EThOS from inception to December 2020. We included studies which focused on rehabilitation potential and/or assessing for rehabilitation interventions for older people with comorbidities in the hospital and community setting. Reviewer pairs independently screened articles and extracted data against the inclusion criteria. A descriptive narrative approach to analysis was taken.

Results

13,484 papers were identified and 49 included in the review. Rehabilitation potential was found to encompass two different but interrelated concepts of prognostication and outcome measurement. 1. Rehabilitation potential for prognostication involved the prediction of what could be achieved in programmes of rehabilitation. 2. Rehabilitation potential as an outcome measure retrospectively considered what had been achieved as a result of rehabilitation interventions. Assessments of rehabilitation potential included key domains which were largely assessed by members of the multi-disciplinary team at single time points. Limited evidence was identified which specifically considered rehabilitation potential amongst older people living with frailty.

Conclusions

Current approaches to rehabilitation potential provide a snapshot of an individual’s abilities and conditions which fail to capture the dynamic nature and fluctuations associated with frailty and rehabilitation. New approaches to measures and abilities over time are required which allow for the prognostication of outcomes and potential benefits of rehabilitation interventions for older people living with frailty.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02498-y.

Does rehabilitation setting influence risk of institutionalization? A register-based study of hip fracture patients in Oslo, Norway

Background

Reducing the economic impact of hip fractures (HF) is a global issue. Some efforts aimed at curtailing costs associated with HF include rehabilitating patients within primary care. Little, however, is known about how different rehabilitation settings within primary care influence patients’ subsequent risk of institutionalization for long-term care (LTC). This study examines the association between rehabilitation setting (outside an institution versus short-term rehabilitation stay in an institution, both during 30 days post-discharge for HF) and risk of institutionalization in a nursing home (at 6–12 months from the index admission).

Methods

Data were for 612 HF incidents across 611 patients aged 50 years and older, who were hospitalized between 2008 and 2013 in Oslo, Norway, and who lived at home prior to the incidence. We used logistic regression to examine the effect of rehabilitation setting on risk of institutionalization, and adjusted for patients’ age, gender, health characteristics, functional level, use of healthcare services, and socioeconomic characteristics. The models also included fixed-effects for Oslo’s boroughs to control for supply-side and unobserved effects.

Results

The sample of HF patients had a mean age of 82.4 years, and 78.9 % were women. Within 30 days after hospital discharge, 49.0 % of patients received rehabilitation outside an institution, while the remaining 51.0 % received a short-term rehabilitation stay in an institution. Receiving rehabilitation outside an institution was associated with a 58 % lower odds (OR = 0.42, 95 % CI = 0.23–0.76) of living in a nursing home at 6–12 months after the index admission. The patients who were admitted to a nursing home for LTC were older, more dependent on help with their memory, and had a substantially greater increase in the use of municipal healthcare services after the HF.

Conclusions

The setting in which HF patients receive rehabilitation is associated with their likelihood of institutionalization. In the current study, patients who received rehabilitation outside of an institution were less likely to be admitted to a nursing home for LTC, compared to those who received a short-term rehabilitation stay in an institution. These results suggest that providing rehabilitation at home may be favorable in terms of reducing risk of institutionalization for HF patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06703-x.

Foot disease and physical function in older adults: A systematic review and meta-analysis

OBJECTIVES

To systematically assess the literature examining the association between foot disease (foot ulceration, infection, critical ischaemia and/or Charcot neuroarthropathy) and physical function in older adults.

METHODS

Literature search of MEDLINE, Embase and CINAHL was performed. Studies were included if foot disease and physical function were assessed in participants of mean or median age ≥ 65 years.

RESULTS

Of 2,574 abstracts screened, 19 studies (13 longitudinal, 6 cross-sectional) reporting on 5634 participants, 43% female, were included. Diabetes-related foot disease and critical ischaemia were most studied (n = 5017, 40% female). In 8 studies with control groups, foot disease was associated with poorer physical function. Meta-analysis of 5 studies (n = 1503, 45% female) found an association between foot disease and poorer physical function (SMD (95% CI): 1.00 (0.40, 1.62), P < 0.001).

CONCLUSION

Foot disease is associated with poorer physical function in older adults. Future research should include broader study populations and intervention strategies.

Continuity of care for patients with hip fracture after discharge from rehabilitation facility

Background and aims of the work: Hip fracture is a dramatic event especially in the elderly and the return to the pre-fracture functional and social state is often difficult to achieve. In the post-acute, the intensive rehabilitation period aims to recover as much autonomy as possible to these patients, but not always its duration is sufficient to ensure an effective and lasting result in returning home, hence the need for additional rehabilitation services. Our aim was to evaluate the use of additional rehabilitation services by patients who underwent hip fracture after an intensive rehabilitation treatment period performed at our hospital. Methods: This is a retrospective cohort study. We involved patients aged 45 years and older, admitted at our intensive rehabilitation, who joined a rehabilitation program for a hip fracture. Results: Our results showed how the use of further physiotherapy is associated with the type of surgical intervention and with higher Cumulative Illness Rating Scale CIRS scores. Similarly, the loss of autonomy is associated with the type of intervention, the increase in CIRS and the duration of the physiotherapy, and negatively associated with the duration of each session. The re-hospitalizations for each cause is positively associated with CIRS and negatively associated with the further use of physiotherapy. Conclusions: Our conclusion is that rehabilitation needs a personalized schedule, because the real discriminating factor in the management of frail patients should therefore be the quality, and not the quantity (i.e. longer session), of the rehabilitative intervention prescribed. (www.actabiomedica.it)

Health-care professionals' experiences of patient participation among older patients in intermediate care-At the intersection between profession, market and bureaucracy

Background

Patient participation is a key concern in health care. Nevertheless, older patients often do not feel involved in their rehabilitation process. Research states that when organizational conditions exert pressure on the work situation, care as a mere technical activity seems to be prioritized by the health‐care staff, at the expense of patient involvement.

Objective

The aim of this article is to explore how health‐care professionals experience patient participation in IC services, and explain how they perform their clinical work balancing between the patient's needs, available resources and regulatory constraints.

Design

Using a framework of professional work and institutional logics, underpinned by critical realism, we conducted semi‐structured interviews with 18 health‐care professionals from three IC institutions.

Results

IC appears as an important service in the patient pathway for older people with a great potential for patient participation. However, health care staff may experience constraints that prohibit them from using professional discretion, which is perceived as a threat to patient participation. Further, they may adopt routines that simplify their interactions with patients. Our results call for more emphasis on an individualized rehabilitation process and a recognition that psychological and social aspects are critical for patient participation in IC.

Conclusion

Patients interact in the face of conflicting institutional priorities or protocols. The study adds important knowledge about the practice of patient participation in IC from a front‐line provider perspective. Underlying mechanisms are identified to understand and recommend how to facilitate patient participation at different levels in narrowing the gap between policy and clinical work in IC.

Reabilitação pós-AVC: identificação de sinais e sintomas fonoaudiológicos por enfermeiros e médicos da Atenção Primária à Saúde

RESUMO Objetivo O Acidente Vascular Cerebral (AVC) é um agravo comum para a população e um problema para a saúde pública global em termos de mortalidade, deficiência e demanda de custos. O objetivo deste estudo é verificar quais grupos de comorbidades ligados aos distúrbios fonoaudiológicos são identificados por médicos e enfermeiros das equipes de Estratégia de Saúde da Família (ESF) para encaminhamento à reabilitação fonoaudiológica e continuidade do cuidado de pacientes pós-AVC nas Atenções Primária e Secundária à Saúde (APS). Método Participaram 22 médicos e enfermeiros das equipes de ESF apoiadas pelo Núcleo de Apoio à Saúde da Família, no sul do Brasil. Um questionário desenvolvido para este estudo foi respondido, explorando variáveis sociodemográficas, histórico de formação, atuação profissional e condutas ao paciente com AVC. Análise descritiva dos dados (frequências absoluta e relativa) foi realizada no Software SPSS 22. Resultados Dos entrevistados, 77,3% encaminham pacientes pós-AVC para fisioterapia e 54,5%, para reabilitação fonoaudiológica. Nenhum profissional realiza encaminhamento por sequelas cognitivas de compreensão; 90,0% encaminham por distúrbios de linguagem expressiva na fala. Para alterações do sistema estomatognático, 80,0% dos médicos não encaminham para fonoaudiólogo e 83,3% dos enfermeiros o fazem. Conclusão Os profissionais demonstraram dificuldade em identificar distúrbios fonoaudiológicos ligados à cognição e ao sistema estomatognático, não encaminhando para reabilitação fonoaudiológica nas Atenções Primária e Secundária à Saúde. Os resultados apontam para a necessidade de ações que auxiliem no processo de educação permanente e melhorem o conhecimento das equipes de APS, para que as sequelas fonoaudiológicas sejam devidamente identificadas e encaminhadas para reabilitação.

Effectiveness and cost-effectiveness of a health coaching intervention to improve the lifestyle of patients with knee osteoarthritis: cluster randomized clinical trial

Background

The prevalence of osteoarthritis and knee osteoarthritis in the Spanish population is estimated at 17% and 10.2%, respectively. The clinical guidelines concur that the first line treatment for knee osteoarthritis should be non-pharmacological and include weight loss, physical activity and self-management of pain. Health Coaching has been defined as an intervention that facilitates the achievement of health improvement goals, the reduction of unhealthy lifestyles, the improvement of self-management for chronic conditions and quality of life enhancement.

The aim of this study is to analyze the effectiveness, cost-effectiveness and cost-utility of a health coaching intervention on quality of life, pain, overweight and physical activity in patients from 18 primary care centres of Barcelona with knee osteoarthritis.

Methods/Design

Methodology from the Medical Research Council on developing complex interventions. Phase 1: Intervention modelling and operationalization through a qualitative, socioconstructivist study using theoretical sampling with 10 in-depth interviews to patients with knee osteoarthritis and 4 discussion groups of 8–12 primary care professionals, evaluated using a sociological discourse analysis. Phase 2: Effectiveness, cost-effectiveness and cost-utility study with a community-based randomized clinical trial. Participants: 360 patients with knee osteoarthritis (180 in each group). Randomization unit: Primary Care Centre. Intervention Group: will receive standard care plus 20-hour health coaching and follow-up sessions. Control Group: will receive standard care. Main Outcome Variable: quality of life as measured by the WOMAC index. Data Analyses: will include standardized response mean and multilevel analysis of repeated measures. Economic analysis: based on cost-effectiveness and cost-utility measures. Phase 3: Evaluation of the intervention programme with a qualitative study. Methodology as in Phase 1.

Discussion

If the analyses show the cost-effectiveness and cost-utility of the intervention the results can be incorporated into the clinical guidelines for the management of knee osteoarthritis in primary care.

Trial registration

ISRCTN57405925. Registred 20 June 2014.

[Health and social services used by the rural elderly]

OBJECTIVES

To describe the use of health and social services, and to analyze the influence of functional capacity for Instrumental Activities of Daily Living (IADL) and other factors in their use.

METHOD

Cross-sectional study in a non-institutionalized population older than 64 years old in a basic rural health area of Zaragoza.

DEPENDENT VARIABLES

use of different health and social services. Main independent variable: functional capacity for IADL according to the Lawton-Brody. Confounding variables: sociodemographic, physical exercise, comorbidity, self-perceived health, walking aids, social resources and economic resources (OARS-MAFQ). The relationship between the use of services and functional capacity for IADL was assessed using crude OR (ORC) and adjusted (adjusted OR) with CI95% by means of multivariate logistic regression models.

RESULTS

The use of social and health services increased with age and worse functional capacity for IADL. The increased use of health services was related with bad stage of health, limited social and economic resources, physical inactivity and female. The increased use of home help services was related with limited social resources, low education level and male. Regular physical activity and using walking aids were associated with greater participation in recreational activities.

CONCLUSIONS

The probability of using social and health services increased in older people with impaired functional capacity for IADL. The specific use of them changed according to differences in health, demographic and contextual features.